ARTICLES ENJOY A VARIETY OF FOODS — There are several diet-related public health concerns in South Africa. Food-Based Dietary Guidelines (FBDGs) have been DIFFICULT BUT NECESSARY IN proposed to attempt to resolve many of these public health DEVELOPING COUNTRIES problems.1 As outlined in the introductory paper 1 South Africa is a society in transition with a double burden of diseases related to both under- and overnutrition. Poorer populations E M W Maunder, J Matji, T Hlatshwayo-Molea have problems of stunting, micronutrient deficiencies and a greater risk of infectious disease, while both richer and poorer populations are more prone to obesity and chronic ‘Enjoy a variety of foods’ is the first of the ten South African degenerative diseases. Food-Based Dietary Guidelines (FBDGs). This guideline ‘Enjoy a variety of foods’ is the first of the ten FBDGs. This attempts to focus on some of the consequences arising from a guideline attempts to focus on some of the consequences lack of dietary variety. Its aim is to encourage people to arising from a lack of dietary variety. Results of the 1999 change their diets where necessary so as to increase the National Food Consumption Survey in South Africa showed variety of foods eaten and to enjoy their food. The guideline that the diets of many households, particularly lower income needs to be understood in the context of the other FBDGs and households, have low dietary variety.2 The aim of this guideline to be applied with the assistance of appropriate food guides. is to encourage people to change their diets where necessary so For both consumers and nutritional scientists, variety is as to increase the variety of foods eaten and to enjoy their food. conceptualised as including different foods and different food The guideline needs to be understood in the context of the groups as part of the diet, as well as altering the method of other FBDGs and to be applied with the assistance of a food food preparation. In addition, for the consumer, variety is guide. important in order for the taste preferences of the household The aim of this paper is to discuss the rationale and scientific to be accommodated as well as ensuring that the family background for the recommendation to enjoy a variety of enjoys their food. foods. It should be noted that the FBDGs are for children aged Prevalent low micronutrient intakes and low energy 5 years and older and for all ‘healthy’ South African adults intakes, as well as overconsumption of food with the (excluding pregnant and lactating women). associated increased risk for chronic diseases of lifestyle, are addressed. CONCEPTUALISATION OF THE FBDG ‘ENJOY A There are, however, a number of potential problems which VARIETY OF FOODS’ may arise from this guideline. The high levels of household food insecurity in South Africa will be a constraint on the Conceptualisation of dietary variety by nutritional implementation of this guideline. Increasing dietary variety scientists could be interpreted as increasing the number of processed Nutritional scientists are interested in quantifying and foods of low micronutrient and phytochemical content, describing dietary variety because of possible relationships particularly in the urban context. Obesity is a problem for between dietary variety and the nutritional quality of the diet some sections of the population in South Africa and and between dietary variety and the health of people increasing dietary diversity could lead to increased energy consuming the diet. intakes and obesity. Therefore, formulation of appropriate Dietary variety can be conceptualised and measured in a food guides and other measures are important to address number of ways. The choice of index that is used to assess these problems and to ensure that increasing dietary variety dietary variety is therefore important, since the use of different leads to increased intakes of appropriate foods that are good indices may lead to different conclusions regarding sources of micronutrients. The challenge is to ensure that relationships with dietary variety. Two primary approaches these goals are achieved within the context of high household have been used to create an index of dietary variety. The first is food insecurity and increasing urbanisation. the calculation of a score based on the numbers of individual foods consumed. The second is to group foods into major and minor food groups, and derive a score based on the number of S7 food groups consumed. 3 A key issue in determining the dietary Discipline Dietetics and Human Nutrition, University of Natal variety score is determining which foods should count as the E M W Maunder, BSc Nutr, PG Dip Diet, PhD same or different items. 4 UNICEF, South Africa Nutritional scientists argue that it is useful to examine the J Matji, BSc Nutr, MSc Nutr diets that people consume in terms of a global index of the Institute for Human Nutrition, MEDUNSA variety of foods eaten. Human diets are complex. In addition to T Hlatshwayo-Molea, BSc Diet ARTICLES examining individual nutrients and other food constituents, as part of the diet, as well as altering the method of food there are many nutrient-nutrient interactions. Therefore, it is preparation. Nevertheless, nutritional scientists try to define difficult to draw conclusions regarding the effects of a single dietary variety more precisely and quantitatively in order to food or nutrient on health outcomes.5 Furthermore, our enable them to formulate and test hypothesis regarding the nutritional knowledge is incomplete, but expanding relationship of foods, dietary quality and disease, whereas the continuously, both in terms of nutrients and non-nutrients consumer had a greater emphasis on the taste and enjoyment present in food that may impact on public health. Therefore, it of food, which provides a useful background to the is important to advocate the consumption of a variety of foods formulation of appropriate nutrition education. to ensure that there is a positive outcome on health, notwithstanding the limitations in our knowledge. In DIETARY DISORDERS OF PUBLIC HEALTH particular, it is important to ensure that the biodiversity of food SIGNIFICANCE sources is maintained and nutrient-dense foods are consumed. A lack of dietary variety is thought to contribute to: Conceptualisation of dietary variety by South • low micronutrient intakes African consumers • low energy intakes Focus-group discussions with Xhosa, Zulu, Afrikaans and • chronic diseases of lifestyle. English consumers in the KwaZulu-Natal and Western Cape provinces of South Africa, among urban (formal and informal) Low micronutrient intakes and rural populations, showed that dietary variety was Dietary diversification is one of the four main strategies conceptualised as including different foods and different food advocated internationally for the improvement of groups as part of the diet. 6 This was achieved both by varying micronutrient status in undernourished individuals. the composition of foods used in each meal as well as varying A guideline on dietary variety has been substantiated in the composition of meals from day to day. In addition, in other countries on the basis of the need to consume more than households where there are few foods available, altering the 40 different essential nutrients. This is felt to be particularly method of food preparation was cited as a means of increasing important in relation to nutrients which are found only in a dietary variety. All groups thought that the part of the few foods such as vitamin A and its precursors, calcium, iron guideline referring to variety was important in order for the and vitamin C. When few such foods are consumed, intakes of taste preferences of the household to be accommodated, as well these particular nutrients may be lacking.7 as ensuring that the family enjoyed their food and received the required nutrients. Data from the 1999 National Food Consumption Survey of children aged 1 - 9 years in South Africa,2 showed that low These different interpretations of dietary variety can be income households had only a few foods present in the house, viewed as complementary and as addressing differing specific that few foods were consumed by the children and that low public health problems. micronutrient intakes were widespread. The same survey The word ‘enjoy’ was understood as meaning to be satisfied showed that the average number of foods consumed in low or happy with and liking the food. It is interesting to note that income households nationally was 8 and varied from 4 in the in the situation of household food insecurity, focus-group Free State to 13 in the Western Cape, indicating a low dietary participants talked about enjoying food in the sense of being variety. The foods found most frequently in the household lucky to have food. The focus-group participants also inventory of lower income households (< R12 000 per understood the term enjoy to refer to enjoying foods which household per year) were maize, salt, white sugar, tea, fat/oils, fitted in with household taste preferences. In addition, it is white rice and white bread. These foods, together with brown interesting to note that household taste preferences could lead bread and hard margarine, were the foods most frequently to the exclusion of certain foods. consumed by all children in the survey on the basis of the 24-hour recall (24 HR) method. All other foods listed (24 HR) Reflections on the conceptualisation of dietary such as chicken, beef, cabbage and squash, were consumed by variety by nutritional scientists and by South less than a third of the sample, which is important in relation to S8 African consumers the low micronutrient intakes reported in the survey. Therefore, there is a need for an increased intake of a variety of foods, e.g. It would, therefore, appear that there is much commonality fruits, vegetables, meat and legumes which will also contribute between the conceptualisation of dietary variety by nutritional to improving micronutrient status. scientists and by South African consumers. In this regard, both Food consumption data from North America have shown nutritional scientists and consumers conceptualised dietary that variety in food choices and dietary quality are related.8 variety as including different foods and different food groups Simply including foods from each of the five major food September 2001, Vol. 14, No. 3 SAJCN (Supplement) ARTICLES groups used in the USA(i.e. milk and milk products, grain Furthermore, two studies in adults, one in France4 and one in products, fruits, vegetables, meat and meat alternatives) the USA,12 have shown an association between increased showed a correlation with the nutritional adequacy, measured dietary variety and increased energy intake. The former study as the mean adequacy ratio (MAR), an index of the percentage used a dietary diversity score based on the number of food of recommended intake for eleven nutrients:protein, calcium, groups consumed, while the second study used an index based iron, magnesium, phosphorus, vitamin A, thiamin, riboflavin, on the number of different food items consumed within food and vitamins B 6, B12 and C. The authors suggest that the groups. simplest approach to interpreting ‘Enjoy a variety of foods’ may be to include foods from each of the five food groups. The Chronic degenerative diseases data also indicate that the addition of only one extra food item South Africa faces overnutrition-related chronic diseases of to a diet of poor dietary variety led to a significant increase in lifestyle such as hypertension, cardiovascular disease, non- MAR, which was not the case when dietary variety was insulin-dependent diabetes mellitus and cancer, which are initially high. prevalent in all population groups. A similar analysis of the South African National Food The observed relationships between diet and chronic Consumption Survey data still needs to be done. However, diseases of lifestyle have been investigated. Many studies have given the low number of food items consumed in the diet from shown that diets high in fruits and vegetables and low in meats the different food groups, and the low reported micronutrient and fats are protective against the development of chronic intakes, one can safely state that an increase in the variety of diseases of lifestyle. It is most unfortunate, however, that food from these food groups will be associated with improved although the relationship shown is based on the consumption micronutrient intakes in South Africa. of specific foods, both scientists and public health professionals This important consideration should be borne in mind in tend to trivialise the importance of wholesome foods by view of the consumer’s interpretation of increasing dietary concentrating on the individual components of the diet and variety by altering methods of food preparation. The latter will their chemical nature.14 In terms of nutrition of the public and not improve the micronutrient intake of the diet where the diet also in terms of scientific understanding, working with foods consists of a few foods/few food groups and has a low rather than any one of their components has much to be micronutrient content. recommended. In this regard Wahlqvist and Specht 15 have Low energy intakes shown that the food pattern most protective against disease is one of food diversity, which is defined as using probably 20 - The National Food Consumption Survey 2 showed that there 30 biologically distinct foods in a week. were widespread low energy intakes in children aged 1 - 9 Several investigators have studied the relationship between years. The number of foods consumed by these children was dietary diversity (measured as an index based on food or food also low.2 Low energy intakes in developing countries have groups) and disease outcome 3 and many but not all have found been ascribed to the lack of available food, and also type of an inverse relationship between increased dietary diversity and foods available, e.g. the low fat content of many African diets.9 mortality (all cause), cancer and cardiovascular disease. Low energy intakes could be increased by increasing the A r ecent analysis by Kant et al.5 found an inverse correlation variety of foods eaten. Golden 13 has suggested that nutrients between the Recommended Food Score and all cause mortality can be divided into types I and II and that deficient intakes of in American adults. The Recommended Food Score is the score type II nutrients, e.g. zinc, are associated with anorexia. It can derived by comparing the number of foods reported to be be postulated that a vicious cycle is set up when low dietary eaten at least once a week with those recommended by current variety is associated with reduced energy and micronutrient dietary guidelines, i.e. fruits, vegetables, whole grains, low fat intakes and a depression of appetite, further exacerbating the dairy products and lean meats and poultry. The conceptual low energy intakes. Underwood 10 postulated that part of the framework for the food score is therefore broader than using a cause of low energy intakes in developing countries is related dietary variety score which only counts the number of foods, as to the monotomy of the diet. This hypothesis was tested in a suggested by Drewnowski et al.4 clinical study in Peru and the results cited by Brown et al.11 show that in children fed two diets with a similar nutrient It would seem that in relation to the prevention of chronic composition the energy intake was increased by 10% when the diseases of lifestyle, particularly in relation to obesity (see S9 taste, colour and consistency of the diet was varied. This below), this guideline must, as is intended, be used in finding is in line with views expressed by the focus-group conjunction with the other FBDGs to ensure that there is studies on consumers in South Africa, that altering the method sufficient intake of foods containing protective factors and a of food preparation can also be used as a means of increasing reduced intake of foods which are known to increase the risk of dietary variety.6 disease. ARTICLES POTENTIAL PROBLEMS ARISING FROM THE As stated by Gussow and Clancy,17 ‘The proliferating GUIDELINE ‘ENJOY A VARIETY OF FOODS’ ‘variety’ in the supermarkets does not reflect an equivalent biological variety ... Thus nutritionists must help consumers The FBDG work group recognises that there may be a number learn to create a demand for a wider variety of whole foods of problems which arise in implementing this guideline, instead of a succession of food novelties whose claim to namely: diversity is based on processing techniques and artificial colors • The high levels of household food insecurity in South Africa. and flavors.’ This is particularly true in view of the findings of • The recommendation of increasing dietary variety could be Bourne,18 which have shown that with migration to urban areas misinterpreted as increasing the number of processed foods, in South Africa, increased urban exposure was associated with which in the urban context at least, could lead to an increase an increased atherogenicity of the diet of African adults, in the consumption of processed foods of poor micronutrient namely an increase in the proportion of energy supplied by fat and phytochemical content. and a decrease in the proportion of energy supplied by • Increasing dietary diversity could lead to an increased carbohydrate. In terms of foods this was related to a decreased dietary energy intake, thereby exacerbating the increasing consumption of dairy foods and cereals and an increased prevalence of obesity in certain sections of the South African consumption of meat, and also of non-basic foods or nutrient- population. empty foods, such as potato crisps and carbonated drinks. Of further particular interest to the issue of dietary variety is the Household food insecurity and other barriers finding of Bourne et al.19 that the urban diet was confined to a On the basis of the available evidence there can be little doubt relatively narrow range of foods, with low intakes of dairy that it would be desirable to increase dietary variety of South products and fruits and vegetables. A later survey involving all African diets, particularly of people living in low income population groups also showed that intakes of dairy products households. However, achieving this goal will be most difficult and fruits and vegetables are low, particularly in Asians, for this section of the population because of the constraints of coloureds and Africans.20 poverty. There is ample evidence of household food insecurity The meaning of the guideline should therefore be discussed in South Africa when either indirect or direct indicators are using appropriate food examples. used to measure it. May,16 using indirect economic indicators, has shown high levels of food insecurity, a finding confirmed Increase in obesity by direct measurement of food present in low income The prevalence of obesity is high among some sections of the households by the National Food Consumption Survey.2 population in South Africa. Increasing dietary diversity could The focus-group studies in KwaZulu-Natal and the Western potentially lead to an increased energy intake and therefore Cape also identified affordability as a major constraint, contribute to a further increase in the prevalence of obesity and particularly with regard to fruits, vegetables and foods of associated problems such as diabetes mellitus and animal origin.6 Other problems were time constraints and cardiovascular disease. routine food-purchasing habits.6 Studies investigating the effect of increasing the variety of Because the high levels of food insecurity in South Africa foods at a meal showed that more food is eaten when dietary will make it difficult for people to apply this guideline, the variety is high than if the selection of food is limited.21 Data on implementation of the Poverty Alleviation Programme and sensory-specific satiety by Rolls and McDermott,22 suggest that promotion of income generation are important prerequisites to increasing dietary variety in a manner which leads to different its success. In addition a nutrition education campaign is sensory properties of food does lead to increased energy intake. needed for all the guidelines, including this specific one. This While this is desirable in certain situations, e.g. where the campaign should be sensitive to financial and other constraints, energy intake is lower than requirements, it is not desirable be multisectoral and aim at targeting specific population when it leads to the development of obesity. Rolls 21 warned that groups at different levels of socio-economic status. advice to eat a variety of foods might lead to overconsumption of energy. Food consumption data of a large and varied group Consumption of processed foods of adults in the USAindicate that increased variety within food Particularly in the urban context with an abundance of groups was also associated with increased body fatness and S10 processed foods, increasing dietary variety could be increased energy intakes. Further analysis of the data however misinterpreted as increasing the consumption of processed also showed that this varied within food groups, e.g. increased foods. This could be counterproductive in terms of the aim of variety within the vegetable group was negatively associated this recommendation, particularly in relation to increasing with percentage body fat whereas increased variety within the micronutrient intake and changing the proportions of combined group of sweets, snacks and condiments was macronutrient intakes to reduce the risk of chronic positively associated with the percentage of body fat.12 McCory degenerative diseases. et al.12 concluded that a high variety of sweets, snacks, September 2001, Vol. 14, No. 3 SAJCN (Supplement) ARTICLES condiments, entrees, and carbohydrates, coupled with a low References variety of vegetables, promotes long-term increases in energy 1. Vorster HH, Love P, Browne C. Development of Food-Based Dietary Guidelines for South Africa — the process. S Afr J Clin Nutr 2001; 14: suppl, S3-S6 (this issue). intake and body fatness. In terms of consumer understanding, 2. Labadarios D, Steyn N, Maunder E, et al.The National Food Consumption Survey (NFCS): therefore, in the USAtheDietary Guideline on variety was Children aged 1- 9 years, South Africa . Pretoria:Department of Health, 1999. 3. Kant AK. Indexes of overall diet quality:a review.. J Am Diet Assoc 1996; 96: 785-791. misinterpreted as a licence to consume foods that may not be 4. Drewnowski A, Ahlstrom Henderson S, Shore AB, Fischleer C, Preziosi P, Hercberg S. Diet considered healthy choices, a scenario to be avoided at all costs quality and dietary diversity in France: implications for the French paradox. J Am Diet Assoc 1996; 96: 663-669. in South Africa.23 5. Kant AK, Schatzkin A, Graubard BI, Schairer C. A prospective study of diet quality and mortality in women. JAMA 2000; 283: 2109-2115. The US experience therefore raises three issues to be 6. Love P, Maunder E, Green M, Ross F, Smale-Lovely J, Charlton K. South African food-based addressed in nutrition education of the South African dietary guidelines:testing of the preliminary guidelines among women in KwaZulu-Natal and the Western Cape. S Afr JClin Nutr 2001; 14: 9-19. consumer: firstly, the importance of limiting dietary variety 7. Coulston AM. Limitations on the adage ‘eat a variety of foods’? (Editorial). Am J Clin Nutr 1999; 69: 350-351. within certain food groups where energy intake is adequate 8. Kreb-Smith SM, Smiciklas-Wright H, Guthrie HA, Krebs-Smith J. The effects of variety of and emphasising the importance of fruit and vegetable food choices on dietary quality. J Am Diet Assoc 1987; 87: 897-903. 9. FAO. Agriculture, Food and Nutrition for Africa. Rome: FAO, 1997: 394-395. consumption; secondly, the importance of including 10. Underwood BA. Weaning practices in deprived environments:the weaning dilemma. information about portion sizes; and thirdly, the importance of Pediatrics 1985; 75: 194-198. 11. Brown KH, Dewey KG, Allen LH. Complementary Feeding of Young Children in Developing the guideline on physical activity. Countries: A Review of Current Scientific Knowledge . Geneva:WHO, 1998: 75-76. 12. McCory MA, Fuss PJ, McCullum JE, et al. Dietary variety with food groups: association with energy intake and body fatness in adult men and women. Am J Clin Nutr 1999; 69: 440-447. 13. Golden MHN. The role of individual nutrient deficiencies in growth retardation of children RATIONALE FOR THE USE OF THE TERM ‘ENJOY’ as exemplified by zinc and protein. In: Waterlow JC, ed. Linear Growth Retardation in Less Developed Countries. New York:Nestle, Vevey/Raven Press, 1988: 143-163. Guidance given on the implementation and use of FBDGs by 14. Solomons NW. Adult nutrition and cities — an international perspective. S Afr JClin Nutr 2000; 13: Suppl 1, S13-S22. the FAO/WHO consultation24 included the concept that 15. Wahlquist ML, Specht RL. Food variety and biodiversity:econutrition. Asia Pac JClin Nutr 1998; 7: 314-319. guidelines should be user-friendly and positive without 16. May J. Experience and Perceptions of Poverty in South Africa. Durban:Praxis Publishing, 1998. negative prescriptive clauses. Therefore, in formulating the first 17. Gussouw JD, Clancy KL. Dietary guidelines for sustainability. J Nutr Educ 1986; 18: 1-5. guideline the term ‘enjoy’ has been chosen. The working group 18. Bourne LT. Dietary intake in an urban African Population in South Africa — with special reference to the nutrition transition. PhD thesis, University of Cape Town, 1996. is of the opinion that a recommendation to enjoy eating will 19. Bourne LT, Langenhoven ML, Steyn K, Jooste PL, Nesamvumi AE, Laubscher JA. The food and meal pattern in the urban African population of the Cape Peninsula:the BRISK study. encourage families to share meals, to use meal times to interact, Cent Afr JMed 1994; 40: 140-148. relax and cope with stress — all measures to promote health 20. Langenhoven ML, Wolmarans P, Jooste PL, Dhansay MA, Benade AJS. Food consumption profile of the South African adult population. S Afr J Sci 1995; 99: 523-528. and prevent the risk of disease. The term ‘enjoy’ is included in 21. Rolls BJ. Experimental analysis of the effects of variety in a meal on human feeding. Am J an attempt to ensure this. However, its effectiveness in this Clin Nutr 1985; 42: 932-939. 22. Rolls BJ, McDermott TM. Effects of age on sensory-specific satiety. Am JClin Nutr 1991; 54: regard has not been tested in South Africa. 988-996. 23. Prospect Associates. Dietary Guidelines for Americans Focus Group Study: Final Report. Washington DC: ILSI Human Nutrition Institute, 1998. 24. FAO/WHO. Preparation and Use of Food-based Dietary Guidelines. Report of a Joint FAO/WHO CONCLUSION Consultation. Nicosia, Cyprus: FAO/WHO, 1996. The responses obtained from the focus groups of consumers as well as the thinking of nutrition scientists internationally are in line with the thinking of the Working Group in drawing up the guidelines. While work on dietary variety is ongoing there is scientific evidence to support the inclusion of the use of the FBDG ‘Enjoy a variety of foods’, particularly with regard to increasing micronutrient and energy intakes and protection against the development of chronic diseases of lifestyle. However, careful thought should be given to the formulation of appropriate food guides and other measures so that increasing dietary variety does lead to increased intakes of foods from food groups which are currently infrequently consumed by many South Africans. This is important to ensure that micronutrient and energy S11 intakes increase where appropriate, and at the same time to prevent increased energy intake and obesity in those individuals who already have an adequate energy intake. The challenge which faces South African nutritional professionals is to ensure that these goals are achieved within the context of high household food insecurity and increasing urbanisation.